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General NPI Number Information
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NPI Number | 1710231915
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Entity Type | Organization
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Legal Business Name | NEW IMAGE & WELLNESS
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Dates
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Enumeration Date | 11/09/2012
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Last Update Date | 11/09/2012
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Provider Practice Location Address
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Address Line | 2401 PENNSYLVANIA AVE SUITE 1 A2
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City | PHILADELPHIA
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State | PA
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Zip | 19130-3010
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Country | US
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Telephone | 215-792-3197
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Fax |
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Provider Business Mailing Address
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Address Line | 1924 PARKER AVE
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City | HOLMES
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State | PA
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Zip | 19043-1442
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Country | US
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Telephone | 610-513-8439
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. CHARLES GRIM
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Credential | D.C.
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Telephone | 610-513-8439
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | DC002444L
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License Number State | PA
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